Assess your asthma symptoms and impact

To complete it, please mark a ◉ in the one box that best describes your answer.

1. In the past 4 weeks, how much did your asthma limit your usual activities or enjoyment of everyday life?

2. In the past 4 weeks, how much did your asthma limit you in performing your usual daily activities, including housework, work, school or social activities?

3. In the past 4 weeks, how much did your asthma keep you from socializing?

4. In the past 4 weeks, how often did you feel fed up or frustrated because of your asthma?

5. In the past 4 weeks, how often did your asthma leave you too tired to do work or daily activities?

6. In the past 4 weeks, how often did your asthma keep you from getting as much done at work or at home?

7. During the past 4 weeks, how often have you had shortness of breath?

8. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

9. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as Albuterol, Ventolin®, Proventil®, or Maxair®)?

10. How would you rate your asthma control during the past 4 weeks?

Thank you for completing these questions!